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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3' <br /> m30 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. v, m <br /> SO�iN I�iERmAtJ <br /> OWER(Please Print) M raK&r Snen�o,eE <br /> X au v <br /> 0 <br /> f <br /> '71 <br /> Address Address <br /> gpERtc, W(S 51SS7 (ZJFgST6R <br /> City, State, Zip Code City, State,Zip Code <br /> -)/5 S. r? _$1S( A ` &(O - Ss7 22 I <br /> Telephone Telephone <br /> � .�Ba710 Pr�(�DyN Rcn <br /> Emergen y/Fir o. and Ro Na <br /> SL') Y4: � Ve �&�r- 23 1:46AI-- RI�w U, '�,�L,w, <br /> jj- <br /> Legal Description (as Indicated on tax statement) T <br /> O <br /> Permit(s)Applied for: / o °. <br /> Dwelling V Addition Filling/Grading Camping Unit 3 <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage,addition, etc.) I o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST), and dralydield (DF). 0 a <br /> 3 .Show dimensions In feet afthe following:(a)building to all lot lines,(b)building to center line of road,(c)building Z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m <br /> dated by the owner. <br /> C <br /> PLOT PLAN m <br /> I <br /> N <br /> c <br /> o <br /> N <br /> Z <br /> 5 <br /> IU <br /> ry- m oc � mm � aF n9i <br /> n <br /> I a = M <br /> 4o I h NN v Z H o 023 <br /> c <br /> c � : m <br /> rn : t7� C <br /> I declare that this applMW' accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> edge and belief it is t u orrect d te.I acknowledge that I am responsible for the detail and accuracy of all informa- — « m N O <br /> tion contained in this app (including any accompanying schedule)and I further declare that I recognize that this in ori <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- �, <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have n "' o <br /> access to the above described premises atAny reasonable time for the purpose of inspection. : w 8 m <br /> m 3 n . <br /> m <br /> SIGN HERE ` u d <br /> (signature of oppe di Sre I cyatr Ike W I S '. <br /> l 15L/ L� o <br /> ZONING ADMINI ATOR —� 8 '. <br /> TO SHIP PERMITS MAY BE REQUIRED MAY 2 9 '`�qj I '8 Ian <br /> 9 <br /> 8888888 <br />